CardioExchange Archive

CardioExchange, an NEJM practice community for medical professionals dedicated to improving cardiac patient care, was active from 2009 to 2015. CardioExchange fostered discussion between clinicians from across the globe.

October 2nd, 2012

Long-Term Use of Beta-Blockers Questioned in Certain Patients

Use of beta-blockers was not associated with a lower rate of cardiovascular events in an analysis of data from the Reduction of Atherothrombosis for Continued Health (REACH) registry published in JAMA. Over 44 months’ follow-up, the lack of association was observed in patients with only risk factors for coronary artery disease, known CAD without myocardial infarction, or prior history of MI. The study’s first author, Dr. Sripal Bangalore, shares some of his insights with CardioExchange.

1. What are the clinical implications of this study right now?

The implications are that we should not be extrapolating the beneficial effects of beta-blockers seen in heart failure trials and older post-MI trials to other cohorts such as those with CV risk factors alone or those with CAD without MI. Even in stable patients with prior MI but without heart failure, the study questions the long-term utility of beta-blockers in that cohort.

2. Should guidelines be changed?

The latest ESC secondary prevention guidelines recommend beta-blockers long term only in those with LV dysfunction. The revised ACC/AHA secondary prevention guidelines gives Class I indication to beta-blocker use after MI for up to 3 years but class IIa for longer term treatment. We do not know if 3 years is the way to go and if this is based on any evidence. While short-term treatment with beta-blockers after MI is reasonable, we need more data to continue them long term.

3. Do individuals with CAD die of ischemia?  We ask because anti-ischemic agents (beta-blockers, calcium-channel blockers and nitrates) have not been shown to improve mortality in subjects with CAD.

This is a fantastic question. We know from observation studies that greater the ischemic burden worse the prognosis. However, what we do not know is whether this increase in events with higher ischemic burden is the result of ischemia per se or if ischemia is a marker for atherosclerotic burden. You are correct in that the medication you have listed have not been shown to improve mortality. In fact, this is what we have shown in the analysis from the REACH registry. However, the perception among physicians is different, and there are many who “believe” that these medications save lives.

Categories: Prevention
Tags: ,


You can follow any responses to this entry through the RSS 2.0 feed. Both comments and pings are currently closed.

3 Responses to “Long-Term Use of Beta-Blockers Questioned in Certain Patients”

  1. Cassandra Harrison, MD says:
    October 3, 2012 at 11:07 am

    Are there adverse consequences of continuing beta-blockers beyond three years? What about use of beta-blockers in patients who underwent either surgical or interventional revascularization, should 3 yr. be enough in those individuals?

  2. Joel Wolkowicz, MDCM says:
    October 9, 2012 at 6:34 pm

    I think it’s great that researchers are testing strongly held guideline recommendations that have never been adequately tested. iABP in shock, beta-blockers in stable CAD, HgbA1C levels in Type 2 DM. Remember the CAST trial? Have COURAGE, for the Emperor may have no clothes.

  3. Tina Dobsevage, MD says:
    November 9, 2012 at 12:05 pm

    I still find beta blockers useful for treatment of hypertension in certain patients. I see no evidence for harm in this study and plan to continue using beta blockers for hypertension in selected cases.